National root-cause analysis of 1724 post-colonoscopy colorectal cancers demonstrates avoidable harm.

Background and study aims Post-colonoscopy colorectal cancer (PCCRC) represents a potential missed opportunity to diagnose or prevent colorectal cancer. This study aimed to create a standardised, nationwide audit system to determine why PCCRCs occur and to generate evidence to prevent them. Patients and methods PCCRCs occurring 6-48 months after a colonoscopy were identified from English national datasets and uploaded to a secure portal.

The variation in post-endoscopy upper gastrointestinal cancer rates among endoscopy providers in England and associated factors: a population-based study.

Background: Post-endoscopy upper gastrointestinal cancer (PEUGIC) is an important key performance indicator for endoscopy quality. We examined variation in PEUGIC rates among endoscopy providers in England and explored associated factors.

Methods: The was a population-based, retrospective, case-control study, examining data from National Cancer Registration and Analysis Service and Hospital Episode Statistics databases for esophageal and gastric cancers diagnosed between 2009 and 2018 in England.

Patient safety incidents in endoscopy: a human factors analysis of nonprocedural significant harm incidents from the National Reporting and Learning System (NRLS).

Background: Despite advances in understanding and reducing the risk of endoscopic procedures, there is little consideration of the safety of the wider endoscopy service. Patient safety incidents (PSIs) still occur. We sought to identify nonprocedural PSIs (nPSIs) and their causative factors from a human factors perspective and generate ideas for safety improvement.

Using a dark logic model to explore adverse effects in audit and feedback: a qualitative study of gaming in colonoscopy.

Background: Audit and feedback (A&F) interventions improve patient care but may result in unintended consequences. To evaluate plausible harms and maximise benefits, theorisation using logic models can be useful. We aimed to explore the adverse effects of colonoscopy A&F using a feedback intervention theory (FIT) dark logic model before the National Endoscopy Database Automated Performance Reports to Improve Quality Outcomes Trial study.